Name: Samantha Green Provider: G. Panie, MD Code Status: Full Code Allergies: None known Age: 45 years Weight: 120.6 kg (265.32 b) The nurse obtains a client's vital signs. Which vital sign(s) should the nurse find concerning? Select all that apply. Temperature 102.3 F (39 C) Heart Rate 110 Respiratory Rate. 19 Blood Pressure 86/56 Oxygen Saturation 95% on room air Pain 2/10 Lower back

A. Blood pressure 86/56 mmHg is hypotensive for an adult. Normal adult blood pressure is typically around 120/80 mmHg, and values this low can indicate impaired perfusion to vital organs, which may result from dehydration, sepsis, heart failure, or blood loss. Hypotension in combination with other abnormal vitals such as fever and tachycardia increases the concern for systemic compromise. The nurse should assess for signs of poor perfusion, including altered mental status, cool extremities, and delayed capillary refill, and notify the provider promptly. B. Temperature 102.3°F (39°C) indicates a febrile state, which is clinically significant. Fever may be a sign of infection, inflammation, or other systemic illness. In combination with hypotension and tachycardia, this raises concern for early sepsis, a potentially life-threatening condition. The nurse should monitor trends, obtain cultures if ordered, and implement interventions to control the fever and address the underlying cause. C. Oxygen saturation 95% on room air is generally within normal limits for most adults, as normal SpO₂ is typically 95–100%. Although slightly lower than ideal in some high-risk clients, this value does not require immediate intervention and is not as concerning as the other abnormal vitals. D. Heart rate 110 bpm is tachycardic, as the normal adult range is 60–100 bpm. Tachycardia in this context may represent a compensatory mechanism in response to hypotension, fever, or early infection. Persistent or worsening tachycardia warrants close monitoring and further evaluation to determine underlying causes such as hypovolemia, sepsis, pain, or anxiety. E. Respiratory rate 19 is within the normal adult range of 12–20 breaths per minute. Although monitoring should continue, this value is not immediately concerning. F. Pain 2/10 is mild and does not indicate a physiologic emergency. While pain assessment and management are important for comfort and healing, this level of pain is not a priority concern in this scenario.